Neonatal Flashcards
Gastroschisis Description
defect in anterior abdo wall lateral to umbilicus
herniated intestine /w no covering/sac
no associated abnormalities
omphalocele
incomplete closure of ant abdo wall
herniated bowel, stomach, liver, spleen in peritoneal sac
often other abnormalities
NRP algorithim
dry, stimulate, clear secretions (30secs)
if apnea, gasping or HR < 100: PPV, SpO2 monitor, +/- ECG
HR < 100? Check chest movement, correct PPV. ETT or LMA if needed.
then if HR <60, ETT. Compressions. 100% O2. ECG monitor.
HR still <60, IV epi
HR persistently <60, consider hypovolemia or pneumothorax
if labored breathing or persistent cyanosis only: position + clear airway, supplemental O2 PRN. Consider CPAP.
Preductal SpO2 targets in newborn resusc
1min - 60-65% 2min - 65-70% 3 min - 70-75% 4 min - 75-80% 5 min - 80 - 85% 10 min - 85-95%
changes at birth in circulation
hypoxia –> breath
breathing/O2 –> lower pulm resistance, increased pulm blood flow
loss of placental circulation –> increased systemic vascular resistance, closing FO + DA
prematurity acute + chronic morbidity
acute:
- CNS: asphyxia, IVH, seizures, periventricular leukomalacia
- Resp: RDS, apnea of prematurity (monitoring until 5-8d without apnea)
- CVS: PDA
- GI: feeding intolerance, NEC
- ID: sepsis
- Derm: temp instability
chronic:
- HEENT: ROP, hearing impairment
- Resp: CLD
- CNS: behavioural, LDs, CP, cognitive, seizures
management of late preterm infants (34+)
<35 need NICU, otherwise may not
observe - temp, jaundice, BG, car seat test
careful monitor feeding, weight gain until consistent
risk of readmission
kernicterus diagnosis
only dx on histology (see in basal ganglia)
acute bilirubin encephalopathy diagnosis
= clinical diagnosis
physiologic causes of jaundice
breast feeding jaundice (=not getting enough)
breast milk jaundice (getting enough but reacting to a component)
Pathologic causes of Jaundice
Unconjugated/indirect
- hemolytic: ABO incompatible, fragmentation, spherocytosis/elliptocytosis, G6PD def, PKD, alpha thalassemia
- others: cephalohematoma, bruising, craig najar syndrome, gilberts, sepsis, hypothyroidism
Conjugated/direct
- biliary atresia
- choledocal cysts
- infections: sepsis, viral, TORCH, UTI
- metabolic: galactosemia, A1AT def, hypothyroidism
- long term TPN
- idiopathic neonatal hepatitis
Jaundice work up
universal:
- TSB before discharge / 72h
- blood type & screen
- baby blood type
- G6PD if ethnic group (consider)
If severe/treating:
- DAT (coombs)
- CBC + diff
- smear & retics
- unconj + conj serum bili
- G6PD - if asian or severe
- consider septic w/u (eg if WBC off, etc)
Note: also do DAT if high-intermed risk and mom is group O
Jaundice likely pathologic if
- jaundice at <24hr
- bili rises rapidly or very high
- persists beyond 2 weeks
- conjugated hyperbilirubinemia (does not cause kernicterus or respond to phototherapy – but must workup!)
treatment for hyperbilirubinemia
- phototherapy (blanket, light)
- if severe, IVIG, partial exchange transfusion
how to dx hyperbilirubinemia
- use nomogram of total bili to decide if phototherapy
- if no tx, then use 2nd nomogram to determine risk zone + follow-up needed
- RFs = iso immune hemolytic dx, G6PD, asphyxia, resp distress, lethargy, temp instability, sepsis, acidosis
lines: 38+well, 35-38 + wll or term /w RFs, 35-38 with RFs
signs of kernicterus
hypertonia, arcing, retrocolis, fever, opthisthotonos, high pitched cry
tx of kernicterus
exchange transfusion
risk factors for neonatal sepsis
ROM > 18hr intrapartum fever maternal GBS prev infant with GBS chorioamnionitis prematurity perinatal asphyxia
micro-organisms for neonatal sepsis
GBS E coli Strep Viridans Strep pneumo enterobacter S aureus H flu HSV enteroviruses
presentation of neonatal sepsis
non-specific/subtle poor feeding lethargy vomiting resp distress/grunting/apnea temp instability low tone tachycardia fever or hypothermia seizures petechiae
full septic workup
CBC blood cultures urinalysis + culture LP - CSF anlalysis, culture, viral PCR \+/- CXR, stool testing
when to do a workup for sepsis
unwell - full w/u
well and multiple RF or chorio: do CBC after 4 hrs
one RF: observe for 24hr, +/- CBC
empiric antibiotics for neonatal sepsis
ampicillin + gent or cefotaxime
add vanco if >30d, if ?meningitis, or if lines in
add acyclovir if ?HSV
Ddx for neonatal resp distreass
most common:
- transient tachypnea of newborn
- respiratory distress syndrome
- meconium aspiration syndrome
less common:
- infection (pneumonia, sepsis)
- persistent pulmonary HTN
- pneumothorax, effusion, lung hemorrhage
